Nationally, there are more than 540,000 children in enrolled in foster care, and more than 5,000 in Baltimore alone. While there are advantages for these children over their counterparts in institutions, they present with a myriad of medical issues ranging from behavioral problems and developmental delays to child abuse and chronic physical disabilities. Also, many are left without medical care, as well as financial and social support, after they “age out” of the foster care system at 18 years of age.
“There remains a persistent and growing need to provide quality, comprehensive care for these children who have had the misfortune of being orphaned or the victims of neglect or abuse,” noted pediatric resident Marc Callender at a recent Hopkins Children’s Grand Rounds.
In his presentation – “Foster Care in America: How Did We Get Here and Where Do We Go From Here?” – Callender described an experience that has evolved from exploitive indentureship in colonial times to institutionalism in the early 1900s to family based care today. Along the way the establishment of the Societies for the Prevention of Cruelty to Children in the late 19th century granted police powers to remove children from their biological homes due to abuse or neglect, triggering a tripling of orphanages between 1865 and 1890. C. Henry Kempe’s “The Battered-Child Syndrome” (JAMA 1962), prompted states to pass legislation mandating professionals to report suspected instances of child abuse, and passage of the Child Abuse Prevention and Treatment Act came in 1972.
While the issue of child abuse was illuminated, children raised in institutions demonstrated marked developmental delays, poorer physical growth, and marked deficits in competence (Journal of Child Psychology and Psychiatry 2007;48:2;210-218). Children who resided in foster care scored significantly higher for cognitive achievements than their counterparts in orphanages (Pediatrics 2005;115;e710-e717).
Indeed, the family-based model offers benefits but, as an American Academy of Pediatrics (AAP) policy statement in the March 2002 issue of Pediatrics noted, the number of children in foster care had doubled in the 1990s. In large urban centers, there was a 110 percent increase in foster-care placement for children younger than 5 years – a critical time in the development of trust, self-esteem, empathy and problem solving. Most of these children were placed in foster care because of abuse occurring within the context of parental substance abuse, extreme poverty, mental illness, homelessness, or human immunodeficiency virus. “It is not surprising,” the policy statement reported, “that children entering foster care are often in poor health.”
Although the Child Welfare League of America, in consultation with the AAP, has developed standards of care for foster children, many child welfare agencies lack specific policies for children’s physical and mental-health services. The Foster Youth Transitions to Adulthood Study showed that young adults graduating from foster-care programs often experience mental illness, criminality, and limited ability to function independently. Historically, Callender noted, child welfare has not been held accountable for performance outcomes related to children in foster care.
“The outcomes for many graduates of the foster-care system are sub-optimal, and indicate the need for continued reform,” Callender said.
The AAP, Callender added, stresses that all children in fostercare receive initial health screenings and comprehensive assessments of their medical, mental, dental health, and developmental status, the results of which are included in court-approved social services plans. Also, pediatricians can play a critical role in helping birth families and foster families minimize the trauma of placement separation.
"We need to pay particular attention to their mental health needs, as many have endured challenging life transitions," Callender said. "We also need to educate foster-care parents about the needs of these children, and encourage their full engagement at home and in school."
Barriers to care exist, however, and pediatricians must be prepared to provide necessary care even when little or no specific information about the child is available at the time of the visit.
“The take home for all of us, especially pediatricians," Callender concluded, "is to help advocate for this growing population and to understand the extent of current frictions and future implications."